An accelerated path to competency-based medical education at Queen’s

Guest blog by Dr. Damon Dagnone, an Assistant Professor in the Department of Emergency Medicine and the Faculty Lead for CBME at Queen’s University.

For centuries, physicians have occupied a unique place in society. We are privileged to hold positions that are respected, trusted, well-compensated, and considerably more autonomous than those found in most other professions. In return, we provide kind, compassionate, and competent care to those in need. We also devote years of our lives to education, with many of us today spending up to fifteen years in university and residency while we learn our craft. Finally, but certainly not least of all, it is our responsibility under this ‘social contract’ to educate the next generation of physicians.

While those of us at Queen’s are proud to care for our patients, and to continue to learn and grow as physicians through faculty development, we are perhaps most aware of our roles as educators of students, clerks, residents, and fellows. Many of us have been witness to significant changes in the healthcare needs of our patients. Accordingly, it is our societal obligation to constantly adapt our methods of teaching to ensure that our graduates remain kind, compassionate, and above all, competent physicians who will ultimately be better doctors than we ourselves have been.

One of our key challenges as medical educators is to correctly identify new educational practices that will benefit our learners. I am very pleased to say that that’s where we find ourselves today; we have found a better way to educate physicians and we have begun to plan changes to our curricula in ways that will provide our trainees with maximum benefit yet minimum disruption.

Through a partnership with the Royal College of Physicians and Surgeons of Canada (RCPSC), we have set a goal to be the first university in the country to implement competency-based medical education (CBME) across all of our specialty programs. The concept of CBME de-emphasizes time-based learning. Instead of requiring residents to complete a pre-determined period of time (such as one year) at one level before moving on to the next, they will instead be promoted once they have demonstrated competency in a particular field. This ensures that competent residents will move through training in a quicker and more efficient manner, saving valuable resources and shortening their paths to independent practice.

The RCPSC launched its own Competency by Design (CBD) project in 2014 and mapped out a seven-year transition for all specialty programs in Canada. It recommended implementing a more responsive and accountable training model with explicit competencies for all trainees, coupled with more frequent and meaningful assessments. We at Queen’s have not only embraced this concept, but in consultation with the RCPSC, we have taken on a national leadership role by designing and implementing our own parallel, accelerated path to CBME. We have made a commitment that all incoming Queen’s residents will start their training using a CBME-based model by July 2017.

Much work has already been done. Many innovative assessment initiatives have already been introduced across a variety of programs, and a new online assessment and evaluation system – designed and built here at Queen’s – will be launched on July 1st. Together, these projects will facilitate frequent and meaningful feedback on the performance of faculty and residents alike. Programs have also started to identify the multiple tasks that their trainees must be able to perform at the end of residency, known as ‘entrustable professional activities’, as well as the ‘developmental milestones’ that they must achieve along the way.

This is undoubtedly an ambitious goal, yet there is much to support the fact that it is attainable within the timelines that we have set for ourselves. The Department of Family Medicine at Queen’s University, in partnership with the College of Family Physicians of Canada (CFPC), recently transitioned to an analogous competency-based curriculum. Our colleagues in Family Medicine are well-placed to provide our specialty programs with a wealth of expert knowledge and advice drawn from their own experience. Queen’s also benefits from many other assets including a relatively small institutional size, a collegial atmosphere, a centralized funding formula for teaching faculty, a dedicated CBME transition team, outstanding information technology resources, and a Dean who is a world-renowned educational scholar.

During our last accreditation process, the RCPSC and CFPC declared that “education is not just an add-on, it is in the air that is breathed by the faculty at Queen’s.” They praised the dedication of our program directors and stated that they were “blown away” by our remarkable culture of education. They realized something that our faculty, learners, and alumni already know: that the School of Medicine is a special place. In an environment like this, we have every reason to believe that such a huge initiative will be successful. I invite the readers of the Dean’s blog not only to watch this change occur over the next few years, but to become active participants. We welcome your feedback and input, from individual comments below to opportunities for collaboration and partnership. We look forward to hearing from you.

I would like to acknowledge Nicholas Snider, PGME Director of Marketing and Recruitment, for his assistance in writing this blog.

Leslie Flynn

Sincere thanks for your blog Damon and to Richard for providing the opportunity to spread the news. This is an ambitious initiative that will engage all of our faculty and residents. It is particularly exciting because this project has the potential to further identify the Queen’s School of Medicine as a national leader in medical education.

Bola Sogbein

This is an excellent initiative and in fact, long overdue in my opinion. I fully support it. As a current resident, I welcome the CBME vs the time-based approach since the new approach may provide a more formalized venue for residents to identify strengths/weaknesses earlier in the process and work to correct or expand on them respectively. It further incentivizes self-directed and expanded knowledge, which should work well given the general personality type who desires a career in medicine. The counter-argument is the possible establishment of a heirchy of pressure/expectation without formal resources to assist “struggling” residents once identified. As we’re all aware, the pressures for success are profound coupled with sleep deprivation, poor dietary choices etc. If there is the added (albeit likely self-inflicted) pressure to “measure up” to a colleague in the same year or below, one can easily forsee unfortunate scenarios related to burn-out or worse. Whatever is implimented needs to have the flexibility to assist all aspects of the new approach; both the “winners and losers”

J Damon Dagnone, Faculty Lead CBME, PGME Queen's University

Thank you Bola for your very thoughtful and important viewpoints from a residency perspective. It was great to read about your enthusiasm for CBME in residency education at Queen’s and I look forward to future discussions in person. I also am glad you expressed a desire for a careful approach for the implementation of CMBE, making sure all residents factors are taken into account. Our primary goal as a School of Medicine is to support faculty physicians to educate better doctors for tomorrow, which ultimately should result in better quality care for patients and their families. To be successful, we will need to partner with many stakeholders within the hospital, across the university, and beyond our institution. This includes patients, residents, faculty, education scholars, decanal leadership, SEAMO governance, the Royal College of Physicians & Surgeons of Canada, and academic institutions across Canada and beyond. It is a very exciting time for medical education at Queen’s. I agree with you that our path to CBME must provide residents with better education and more opportunities for growth and expertise. This is possible and I look forward to helping get us there as the Faculty Lead at our institution. Thanks again Bola for your important contribution to this discussion.

J Damon Dagnone, Faculty Lead CBME, PGME Queen's University

Bill, thank you for your support of our ambitious path to CBME within the School of Medicine at Queen’s. It is important for alumni to be involved in the discussion. We look forward to more feedback from the Queen’s alumni community.

Bill Moore Meds ''62

Thanks Richard for sharing so much about Queen’s Medical programs, and especially thanks to Dr. Dagone for being so articulate and convincing about current and forthcoming resident Medical education at Queen’s.

reznickr

We won’t get the report for about a month or so. All we get is their “findings” which are, at this point, difficult to interpret without the report. We will keep faculty and alumni posted as soon as we get an official report.

Nicholas Diamant

Being one of those elder retired teachers, I have watched with interest the advances in teaching methodologies and particularly how computers, pads and smart phones are becoming major players, not only in the learning processes and mastering of massive amounts of information, but the actual care of patients. I see students learning from actors playing the role of patients with different disorders.

In taking some clinics for my colleagues it strikes me that the students at different levels that I work with are certainly knowledgeable, kind and compassionate. However some things are often missing. These include the ability to act at a very human physician-patient level in the history taking where that marked individual person and disease variability are always present. Each patient person is different in terms of genetic makeup, life experiences, previous disease and injury, psychological makeup, present social circumstances, etc, etc, and the brain-body-brain-interactions are always complex.

Are the students still being adequately exposed to real patients and taught at that level by experienced teachers of different medical and medically-related disciplines to fill in these important gaps. Hopefully these aspects are part of the CBME.

reznickr

Nick, I think I can say with confidence that we will never replace the patient-student/resdient encounter as the fundamental building block for the study of medicine. We are increasingly using simulation based training, but as an adjunct, not replacement for patient-based training. This won’t change with CBME.

J Damon Dagnone, Faculty Lead CBME, PGME Queen's University

Nicholas, you raise a very important issue of how the act of training physicians must go beyond medical expertise and compassion alone. Physicians must make important therapeutic connections with their patients and benefit from a variety of medical training and life exposures. My own journey within the medical profession has been shaped by the numerous patient interactions, life experiences, mentors, social circumstances, family life, and meaningful relationships I’ve had over time. All of these human-human interactions have helped me grow as a physician and better care for patients and their families as a result. The 2015 CanMEDs roles of medical expert, communicator, collaborator, leader, scholar, professional, and health advocate will continue to serve as the foundation for CBME. Our patients and their families will benefit the most if the students and residents training to be physicians continue to train in an environment that values competencies for all seven roles with a broad exposure to experienced teachers of different disciplines and life experience. Technology is certainly very important, but I agree that it can never replace meaningful human-human interactions that are at the core of providing high quality medical care. Thank you for your contribution and I look forward to more questions that put patient care at the centre of our discussion.

Karen Schultz (Queen's University FM Program Director)

These are exciting times in medical education–thinking about what the competencies are we want our learners to be proficient in and then actually watching and assessing to ensure they are. No matter how we go about competency assessment the common denominator will be watching our trainees more. Our experience so far is that this is picking up areas of development that need correction earlier in training when hopefully the adjustment to get on track is small…as well as being able to reinforce for residents doing well just what it is they are doing that they should continue with. We are excited to be able to work with our Royal College Colleagues and Medical School educators to find a Queen’s approach that works for all learners as well as sharing ideas about new approaches and research.

J Damon Dagnone, Faculty Lead CBME, PGME Queen's University

Karen, thank you for your comments. As you have stated, the benefits of more direct and frequent supervision of trainees will be meaningful for all trainees. We look forward to the expertise and experience you and your Family Medicine colleagues will bring to our Royal College programs.

Furqan Nazeeri

Excellent post, thank you! And commendable work! I’m curious how you map the competencies back to credit hours for course credit or do you have some alternative system in Canada? I’ve seen universities in the US with CBE with some interesting “shadow accounting” systems on the back-end that map competencies to fractional credit hours…here everything from financial aid to school transfers is based around the Carnegie Unit. What are you doing to address this, if this is a concern at all?

reznickr

Thanks for your comment. We really do not have a system of “course credits” with respect postgraduate medical education. It really has not been on our radar. In general, once someone is admitted to a postgraduate program, we currently receive “guaranteed funding” from our provincial government for the number of years associated with the training of a particular specialist. With respect to school-school transfers, we haven’t given this adequate thought, and your question will provoke us to consider this more fully.
Thanks,